Salpingo-ovariolysis by laparoscopy in infertility*

Transcription

1 FERTILITY AND STERILITY Copyright c 1983 The American Fertility Society Printed in U.SA. Salpingo-ovariolysis by laparoscopy in infertility* Victor Gomel, M.D. t Department of Obstetrics and Gynaecology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada Lysis of periadnexal adhesions (salpingo-ovariolysis) by laparoscopy was performed on 92 infertile patients who subsequently have been followed for at least 9 months. In each instance, the duration of infertility was longer than 20 months. Periadnexal adhesions were severe in most cases and moderate in the remainder. Moreover, only those cases where ovum pickup by the oviduct with the lesser pathology was deemed impossible or greatly hampered were included in this series. There were no significant postoperative complications. Of the total of 92 patients, 57 (62%) achieved at least one intrauterine pregnancy, 54 (58.7%) had one Or more full-term pregnancies, and 5 patients (5.4%) had ectopic pregnancies. With appropriately selected patients and in trained hands, laparoscopic salpingoovariolysis is a low-risk procedure associated with a surprisingly good success rate. It can be performed on a day-care basis with considerable savings to the patient in terms of both hospital stay and avoidance of major abdominal surgery. Fertil Steril40:607, 1983 Laparoscopy in the investigation of infertility is well recognized, and the procedure is now widely employed. Previous publications have demonstrated the feasibility and the value of laparoscopic operations to promote fertility.1-3 To date, these operative procedures have not obtained wide recognition; they are utilized infrequently, and there are very few published reports. For these reasons it was thought that a published review of our series of salpingo-ovariolysis (lysis of periadnexal adhesions) by laparoscopy would be timely. Received April 11, 1983; revised and accepted July 20,1983. *Presented at the Tenth Annual Meeting of the American Association of Gynecologic Lapal'9scopists, November 4 to 8, 1981, Phoenix, Arizona. treprint requests: Victor Gomel, M.D., Department of Obstetrics and Gynaecology, Grace Hospital, 4490 Oak Street, Vancouver, British Columbia, Canada V6H 3V5. PATIENTS MATERIALS AND METHODS Laparoscopic salpingo-ovariolysis was performed by the author, on 92 infertility patients who subsequently have been followed for at least 9 months. Their ages ranged from 19 to 38 years. In each instance, the duration of infertility was longer than 20 months. Based on the international classifications sanctioned by the International Federation of Fertility Societies (IFFS),4 periovarian and/or peri tubal adhesions were severe in most (79) and moderate in the remainder (13). Moreover, only those cases where ovum pickup by the oviduct with the lesser pathology was deemed impossible or greatly hampered were included in this series. A third of the patients had adhesions elsewhere in the pelvis as well. Prior to laparoscopy, the couple was investigated for evidence of ovulation. Semen analysis was Gomel Salpingo-ovariolysis by laparoscopy 607

2 Table 1. Salpingo-ovariolysis by Laparoscopy in 92 Patients with Infertility of> 20 Months' Duration Status of contra- No. of Procedure lateral oviduct patients Bilateral 48 Unilateral Hydrosalpinx 25 Absent 12 Cornual occlusion 7 44 Total 92 obtained, and a postcoital test and hysterosalpingography were performed. When laparoscopy was performed as the next logical investigative step, salpingo-ovariolysis was undertaken during this procedure. In other instances, based on the findings of the hysterosalpingography and the prior laparoscopy performed elsewhere, laparoscopic salpingo-ovariolysis was deemed possible and undertaken as an elective procedure. Bilateral salpingo-ovariolysis was performed in 48 patients. Twelve of these, in addition, had fimbrial phimosis present in their adnexa with greater pathology, which required dilatation. In 44 patients unilateral salpingo-ovariolysis was performed, the contralateral oviduct being totally occluded or absent (Table 1). No patient required laparotomy, and there were no postoperative complications. SURGICAL TECHNIQUE The surgical technique involved laparoscopy, adhesiolysis, fimbrial dilatation where necessary, and pelvic lavage. Laparoscopy General anesthesia and endotracheal intubation were employed. The patient was appropriately prepared and draped. The bladder was catheterized, and a pelvic examination was carried out. The uterine cannula was secured to the cervix by means of a single-toothed tenaculum. After the induction of proper pneumoperitoneum, laparoscopy was performed using an intraumbilical entry. A multiple-puncture technique was employed; and even for diagnostic purposes, a 3-mm probe or grasping forceps was inserted suprapubically in the midline. The peritoneal cavity, including the upper abdomen, was inspected. The patient was placed in a sufficient Trendelenburg position to permit mobilization of the bowel and excellent pelvic visualization. The remaining loops of bowel were pushed upward, out of the pelvis, by manipulating the uterus with the uterine cannula. The pelvis then was inspected thoroughly while the uterus and the probe were manipulated as was necessary. Oviductal patency was reassessed by chromopertubation, which was carried out via the cannula using dilute methylene blue solution. When periadnexal adhesions were encountered in the presence of tubal patency, salpingo-ovariolysis was undertaken. Salpingo-ouariolysis Technique While transilluminating the area ofthe abdominal wall, we introduced an appropriate-sized trochar and sleeve through a third puncture, usually placed at the McBurney point. However, depending on the pelvic findings, another somewhat higher point of entry could be selected for the third puncture. The trochar was replaced by 5- mm laparoscopic scissors (Storz #26175PS, Tuttlingen, West Germany). The adhesions were identified and stretched with either probe or 3-mm alligator grasping forceps (Wolf # , Knittlingen, West Germany) introduced through the second puncture. The adhesions were divided individually one layer at a time. Narrow adhesions that were present between structures simply were divided mechanically with the laparoscopic scissors. Frequently the adhesions were long and broad and stretched over the ovary, the tube, or both, extending to the posterior aspect of the uterus, the broad ligament, the pelvic sidewall, or loops of bowel. These adhesions were excised completely, usually by dividing them in the first instance at the distal margin and thereafter adjacent to the tube and ovary. Occasionally, circumstances demanded initial proximal division. With each incision, the demarcation line between the adhesion and the peritoneum, tubal serosa, or the ovary was exposed properly to avoid damage to these structures during the division. All of the excised tissue was retrieved from the pelvis. The alligator grasping forceps were used not only to stretch and expose each additional layer of adhesion, but also to retrieve the excised tissues. The adhesions were divided mechanically. Unipolar electrocoagulation was employed only for the larger vessels crossing the incision line. The surgeon controlled both the ancillary instruments, requiring an assistant to hold the laparoscope in the necessary position. The cooperation between the surgeon and the assistant was greatly facilitated by the use of a teaching arm on the laparo- 608 Gomel Salpingo-ovariolysis by laparoscopy Fertility and Sterility

3 scope. On rare occasions, bleeding persisted from an uncoagulated vessel. In order to visualize this vessel and coagulate it precisely, intraoperative irrigation was performed. The solution of normal Ringer's lactate containing 5000 IU of heparin per liter was injected from a 50-ml syringe by means of a 20- or 22-gauge spinal needle. This needle was introduced through the abdominal wall in the midline. Fimbrioplasty Technique In addition to pelvic and periadnexal adhesions, unilateral fimbrial phimosis was encountered in 12 patients. This phimosis was due to agglutination of the fimbria or, alternatively, the conglutination of these by a serosal layer that covered the terminal end of the oviduct. In the latter instance, the serosal layer was incised or excised with the use of the laparoscopic scissors. To enlarge the fimbrial opening and deagglutinate the fimbria, the 3-mm alligator forceps, its jaws closed, was introduced through the phim?tic ostium. The jaws of the forceps were opened WIthin the tube, and the forceps was gently drawn out of the tube with the jaws open. The procedure was repeated, changing the axis of the jaws until sufficient release of the phimosis and deagglutination of the fimbria was deemed to have occurred. During these procedures, when necessary,the adnexa was immobilized by supporting it with the uterus which was manipulated by the uterine cannuia. The cannula was kept in the desired position by the nurse in attendance. Pelvic Lavage At the completion of the operative procedure, the scissors were replaced by a suction cannula. The pelvis was lavaged with the previously described Ringer's lactate solution, and this fluid was removed by suction. Occasionally, following this final lavage, active bleeding points were noted. They were coagulated with a bipolar electrode that forms part of the suction cannula (Storz #26176UB). Upon completion of the lavage, 150 ml of Ringer's lactate solution containing 250 to 500 mg of hydrocortisone succinate was instilled into the pelvis. Simultaneously, transcervical hydropertubation was carried out using 20 ml of the same solution. The instruments were removed, and the pneumoperitoneum was deflated. Steristrips were applied to the entry sites. Follow-up Any patient who did not conceive within 12 months was offered the opportunity to undergo a second-look laparoscopy. RESULTS The procedures performed and, where appropriate, the status of one tube which was not suitable for laparoscopic repair are shown in Table 1. Of the total of 92 patients, 54 (58.7%) ultimately achieved a full-term pregnancy. There were 57 (62%) who achieved at least one intrauterine pregnancy. Among this group there were two patients who sought termination because of changed social circumstances. A third patient achieved an intrauterine pregnancy that she aborted spontaneously and had not conceived again at the time of this survey. Four of the five patients who experienced one spontaneous abortion have achieved at least o~e full-term pregnancy. Five patients had ectopic pregnancies (5.4%); ofthese, two have also had a term delivery. The total number of intrauterine pregnancies achieved by 57 patients is shown in Table 2. However, 32 patients have either failed to conceive or were lost to follow-up at the time of the survey. Of these, two elected to use contraception. Of the remaining 30 patients at risk for pregnancy, 10 underwent second-look laparoscopy. None demonstrated evidence of a significant residual adhesive process; two had developed stage 1 endometriosis. The intrauterine pregnancies achieved by the different groups of patients (unilateral or bilateral salpingo-ovariolysis, and in the latter group the addition of fimbrioplasty in the adnexa with greater pathology) demonstrated no statistical difference (Table 3). DISCUSSION The largest single cause of infertility is tuboperitoneal disease. That such a problem exists Table 2. Outcome of the Intrauterine Pregnancies Among 57 Patients After Salpingo-ovariolysis Live births Spontaneous abortion Voluntary termination Total Gomel Salpingo-ovariolysis by laparoscopy 609

4 Table 3. Intrauterine Pregnancies After Laparoscopic Salpingo-ovariolysis in 92 Patients with Infertility of> 20 Months'Duration No. of patients Procedure No. of patients who achieved intra- uterine pregnancies a Bilateral Bilateral and additional 12 6 fimbrioplasty in adnexa with greater pathology Unilateral Total _ ap > may be suspected from the patient's history; hysterosalpingography, if abnormal, is invariably followed by laparoscopy. Even in cases of otherwise unexplained infertility, the investigation cannot be considered to be complete untillaparoscopy has been performed. Our primary approach to peri adnexal disease is laparoscopic salpingo-ovariolysis and fimbrioplasty as previously described.1, 3 Such an approach can be achieved only if the following prerequisites are met: (1) general anesthesia with endotracheal intubation; (2) access to the pelvic structures, which can be attained with the Trendelenburg position and effective uterine manipulation with a uterine cannula; (3) availability of the appropriate and well-maintained ancillary instruments; (4) a multiple-puncture technique to permit the separation of the visual and operative axes; (5) freedom of both of the surgeon's hands, which presupposes the presence of an assistant to hold the laparoscope (the efficacy of the assistant is greatly improved if a teaching arm is available); (6) the possibility to separate sufficiently of the structures tethered together (this is essential for safe division of adhesions); and (7) familiarity of the surgeon with both the appearance of the pelvic structures and the details of the operative techniques. Success rates for salpingo-ovariolysis performed at laparotomy range from 32% to 57%.5-10 The success rate in terms of intrauterine pregnancy of62% and oflive births of 58.7% compares favorably with these studies. Despite the fact that all patients had at least one patent oviduct, the ectopic pregnancy rate of 5.4% reflects the proba-. bility that periadnexal disease is not an isolated insult. It is probably associated, in a proportion of cases, with significant endothelial damage. This ectopic pregnancy rate also suggests that these procedures were carried out in a group of patients 610 Gomel Salpingo-ovariolysis by laparoscopy with a significant degree of tuboperitoneal disease. It can be argued that despite the periadnexal adhesions, because all 92 patients had at least one patent tube, it might have been more appropriate to treat or not treat alternate patients on a random basis. In such a fashion, the value of laparoscopic surgery in improving pregnancy rates would have been assessed in a more scientific manner. However, no patient in this series had < 20 months of infertility. It is presently believed that peritubal and/or periovarian disease is a cause of infertility. Such a study of "treatment" versus "no treatment" might be difficult to justify on ethical grounds in view of the almost 60% success rate. Furthermore, of these pregnancies, almost half (46.4%) occurred within 6 months ofthe operative intervention and approximately onequarter (26%) during the first postoperative normal menstrual cycle. It may be argued that laparoscopic fertility-promoting procedures should be abandoned in this era of microsurgery. However, in trained hands laparoscopic salpingo-ovariolysis has a success rate that is comparable with rates obtained by laparotomy; it is a low-risk procedure and is cosmetically very acceptable to the patients. In addition, it can be performed on a day-care or shortstay basis during the final diagnostic step of the patient's investigation. This technique offers considerable savings to the patient in terms of both hospital stay and avoidance of the discomfort, disfigurement, and risk of major abdominal surgery. REFERENCES 1. Gomel V: Laparoscopic tubal surgery in infertility. Obstet Gynecol 46:47, Palmer R: Laparoscopies operatoires dans Ie traitement de la sterilite feminine. Acta Endoscop 1:19, Gomel V: Recent advances in surgical correction of tubal disease producing infertility. In Current Problems in Obstetrics and Gynecology, Vol I, No. 10, Edited by RW Kistner. Chicago, Year Book Medical Publishers, Gomel V: Classification of operations for tubal and peritoneal factors causing infertility. Clin Obstet Gynecol 23:1259, Young PE, Egan JE, Barlow JJ, Mulligan WJ: Reconstructive surgery for infertility at the Boston Hospital for Women. Am J Obstet Gynecol 108:1092, Horne HW, Clyman M, Debrovner C, Griggs G, Kistner R, Kosasa T, Stevenson CS, Taymor M: The prevention of postoperative pelvic adhesions following conservative operative treatment for human infertility. Int J Fertil 18:109, 1973 Fertility and Sterility

5 7. Martius H: Surgical technique in the treatment of sterility in women. Int J Surg 4:70, Arronet GH, Eduljee SY, O'Brien JR: A nine-year survey of fallopian tube dysfunction in human infertility: diagnosis and therapy. Fertil Steril 20:903, Bronson RA, Wallach EE: Lysis of peri adnexal adhesions for correction of infertility. Fertil Steril 28:613, Diamond E: Lysis of postoperative pelvic adhesions in infertility. Fertil Steril 31:287,1979 Gomel Salpingo-ovariolysis by laparoscopy 611